Methods Eighty-one postoperative photographs of patients who had undergone the external lateral osteotomy technique were reviewed. The photographic slides were a mixture of some taken 3 months after surgery and others taken 6 months after surgery. Scar visibility was assessed.

Results Percutaneous puncture site visibility as assessed by 3 surgeons independently was 0% at 6 months after surgery and about 3% at 3 months after surgery.

Conclusion The external osteotomy procedure produces an excellent cosmetic result at the puncture sites in the skin.

THE PURPOSE of using osteotomies in rhinoplastic surgery is to mobilize the nasal bones to produce the desired effect with the least morbidity. Methods of performing the lateral osteotomy in rhinoplastic surgery may broadly be divided into internal and external techniques (Figure 1). Internal techniques include using a curved Neivert osteotome, performing micro-osteotomies through an intranasal incision, or using a Joseph saw.1 More rarely used techniques have included the use of electric saws and cutting forceps.2 One of the earliest reports of the use of a percutaneous external lateral osteotomy approach was by Weir in 1892,3 who used a percutaneous chisel osteotomy or nasal forceps to infracture the lateral nasal wall (Figure 2).

The external lateral osteotomy performed through a small puncture incision in the skin has numerous advantages (Tony R. Bull, FRCS, written communication, 1995). It allows great precision in the placement of the osteotomy, it gives scope for marked narrowing of the nose, and it may be used to make intermediate osteotomies that allow straightening of sharply curved nasal bones.4 Finally, it may also be used for the delayed refracture technique in patients presenting late with a fractured nose. Opponents of the percutaneous external lateral osteotomy technique claim that it may leave visible scars. The aim of this study was to examine the validity of this criticism.

METHODS

Eighty-one postoperative photographs of patients who had undergone the external lateral osteotomy technique at either the Royal National Throat, Nose, and Ear Hospital or St George's Hospital, London, England, were reviewed independently by 3 otolaryngologists, each with training in plastic surgery and each with a special interest in rhinoplastic surgery. The photographic slides were a mixture of some taken 3 months after surgery and others taken 6 months after surgery. These 35-mm slides were projected at life size and at original magnification ×100. Scar visibility for each of the 4 puncture sites in the frontal, lateral, and tip views was assessed. A total of 540 possible visible puncture sites (frontal, lateral, or tip views) were examined by each of the 3 surgeons. Each puncture site was first examined from a distance of 1 m at a life-size magnification. A scar was recorded as either visible or not visible. The exercise was then repeated from an observer distance of 1 m but with the projected slide magnified ×100.

RESULTS

A total of 540 puncture sites were examined by each surgeon for puncture site visibility. Of the patients, 37% were male (n = 30) and 63% were female (n = 51). Seventy percent of the photographs were taken at 3 months and 30% were taken at 6 months.

Puncture site visibility at 3 months, looking at slides at life-size projection, was greatest for surgeon 3, at 6%. Projected at original magnification ×100, the scar visibility was greatest for surgeons 2 and 3, at 9% each (Figure 3).

Puncture site visibility at 6 months at life-size projection was 0% for all 3 surgeons. Projected at original magnification ×100, scar visibility was greatest for surgeon 2, at less than 3% (Figure 4).

Agreement on puncture site visibility between surgeons was poor. At least 2 of 3 surgeons agreed that a puncture site was visibile at 3 months in less than 3% of cases projected at life size and 7% of cases projected at original magnification ×100. All 3 surgeons agreed that a puncture site was visible at 3 months in less than 3% of cases projected at original magnification ×100. All 3 surgeons could not agree any puncture site was visible at 3 months in any case projected at life size (Figure 1).

At least 2 of 3 surgeons could agree on puncture site visibility at 6 months in 1% of the cases projected at original magnification ×100. No 2 of the 3 surgeons could agree on scar visibility in any case when the same cases were projected at life size. On reviewing the slides taken 6 months after surgery, all 3 surgeons could not agree any puncture site was visible at all at either life size or at original magnification ×100 (Figure 2).

An example of a visible site after 3 months agreed on by at least 2 surgeons is shown in Figure 5. Puncture sites with no scarring visible to any surgeon at original magnification ×100 are shown in Figure 6.

COMMENT

The external lateral osteotomy performed through a small puncture incision in the skin has several advantages. It allows great precision in the placement of the osteotomy, and it gives scope for marked narrowing of the nose. The narrowing does not affect the nasal valve or compromise the airway.5 An intermediate longitudinal osteotomy may be used to increase the narrowing along the nasal dorsum. The external percutaneous approach may also be used to make intermediate transverse osteotomies that can be used to straighten sharply curved nasal bones. If 2 banana-shaped nasal bones are mobilized with superior, lateral, and medial osteotomies, there still remain 2 sharply curved nasal bones. If, however, transverse intermediate osteotomies are performed first, this results in 2 half nasal bones on each side of the nose, each piece of the bone with a lesser curve than the whole bone. Much overall straightening of the nasal skeleton results. Finally, external osteotomy may also be used for the delayed refracture technique in patients presenting late with a fractured nose. Nasal bones after a fracture start to fix with callus by 2 weeks, and after this time manipulation, either digital or with instruments, may be impossible. By using superior and lateral external osteotomies, the nasal bones can be mobilized and corrected successfully by manipulation sometimes up to 6 weeks after trauma. Very occasionally, grossly thickened nasal bones can interfere with the percutaneous external lateral osteotomy technique (Figure 7).

The criticism of the percutaneous external lateral osteotomy technique is that it may leave visible scars and can also lead to aesthetically unacceptable bruising if the angular vessels are traumatized. In the present study, we have shown that percutaneous puncture site visibility as assessed by 3 surgeons independently was 0% at 6 months after surgery. No patients in the study commented on the puncture sites either immediately after surgery or after external splint removal 1 week after surgery. Subjectively, our experience is that the percutaneous external lateral osteotomy technique causes less bruising than other methods of performing a lateral osteotomy. Keloid formation in dark-skinned races does not appear to be a problem in the middle third of the face (Tony R. Bull, FRCS, written communication, 1995), but it is a theoretical possibility that should be considered preoperatively when this technique is used.

Experimental evidence examining the results of different lateral osteotomy techniques on cadavers has shown that, although the percutaneous external lateral osteotomy technique produces an irregular osteotomy margin, this method resulted in minimal disruption of the periosteum and very little injury to the nasal mucosa. The percutaneous technique was simple to perform, gave consistent results, and resulted in increased stability of the infractured segment of nasal bone.1 As no periosteal pocket is raised that could collect blood, the likelihood of severe ecchymosis is reduced. The intact areas of periosteum between the perforations act to stabilize the fractured bones.6 A further study comparing the perforating lateral osteotomy and the sliding subperiosteal lateral osteotomy showed that using the perforating technique gave a more stable bony vault, greater contact of all soft tissues to the bone, less dead space along the osteotomy, less airway compromise, and no subluxation of the nasal bones.7

No previous studies have looked specifically at the visibility of puncture sites from the use of the percutaneous perforating lateral osteotomy technique, although the procedure itself has been previously reported.1, 8 It is reassuring that we have confirmed what we expected from our past experience, that no patients are aware of any visibility of the percutaneous puncture sites and, furthermore, 6 months after surgery no experienced rhinoplasty surgeon could detect the puncture sites either.

In conclusion, puncture sites after the percutaneous lateral osteotomy technique are not visible. The external osteotomy procedure has special advantages over other techniques, particularly to narrow the nose, and produces an excellent result at the puncture sites in the skin.